If you are registering for the upcoming school year, please select 'School'.
* must provide value
School Daycare Summer Camp Other School
Daycare
Summer Camp
Other
Please select the school location that your child will be attending in the upcoming school year or is currently attending (if registering in the middle of a school year).
* must provide value
Boonville Middle School Boonville High School Bosse Carver Castle High School Castle North Castle South Caze Cedar Hall Central Chandler Culver Cynthia Heights Daniel Wertz Delaware Dexter Evans Fairlawn Farmersville Gibson Co. - East Gibson Co. - North Gibson Co. - South Glenwood Harper Harrison Hebron Helfrich Highland Homeschooled Joshua Academy Lincoln Lodge Loge Marrs McCutchanville McGary Mt. Vernon Jr. High Mt. Vernon High School Newburgh North Jr. High North High School Oakdale Oak Hill Perry Heights Reitz Plaza Scott Sharon Stockwell Stringtown Tekoppel Thompkins Vogel Washington Middle School West Elementary West Terrace Other
If "Other" was selected, please tell us the name of the school your child attends
* must provide value
Please select the daycare location that your child will be or is currently attending
* must provide value
CAPE Headstart Posey County CAPE Place Enterprise CAPE Place Headstart Headstart Boonville Headstart Newburgh Mt. Vernon Headstart St. Vincent Early Learning Center Other
If "Other" was selected, please tell us the name of the daycare your child attends
* must provide value
Please select the specific summer camp your child will be attending.
YMCA ASV Downtown YMCA Dunnigan YMCA ASV Downtown
YMCA Dunnigan
Please select the community partner your child is registering through
ECHO
I am able to do the following:
Patient First and Last Name (Legal Name)
Patient Social Security Number
Today M-D-Y
View equation Male Female Other
Parent/Guardian Name
* must provide value
Relationship to patient
* must provide value
Parent/Guardian Phone Number
Parent/Guardian Street / P.O. Box Address
For the patient's dental insurance coverage, choose one:
Hoosier Healthwise/Indiana Medicaid
Other Dental Insurance
No Dental Insurance coverage
Hoosier Healthwise/Indiana Medicaid
Other Dental Insurance
No Dental Insurance coverage
If the patient is not covered with dental insurance, please select one of the following options:
Assistance requested for enrollment in Hoosier Healthwise/Indiana Medicaid
Please contact me with more information regarding payment options and financial assistance.
I do not wish to receive assistance with enrollment or information regarding payment options and financial assistance
Assistance requested for enrollment in Hoosier Healthwise/Indiana Medicaid
Please contact me with more information regarding payment options and financial assistance.
I do not wish to receive assistance with enrollment or information regarding payment options and financial assistance
Please provide Patient ID for Hoosier Healthwise/Indiana Medicaid
Policy Holder Date of Birth
Insurance Plan Name and Address
Has your child seen a dentist in the last six month?
Yes - child was seen at Pediatric Mobile Dental Clinic
Yes - child was seen at another dental practice, but wishes to transfer care
No
Yes - child was seen at Pediatric Mobile Dental Clinic
Yes - child was seen at another dental practice, but wishes to transfer care
No
If your child was seen at another dental practice, please provide the name
Is your child currently a patient of Ascension St. Vincent's Pediatric Dental Clinic?
Yes No
Has your child complained about dental problems?
Yes No
The option "
Does your child have any of the following habits?
Please add any additional detail below regarding noted habits
Has your child been informed by a provider that he or she needs to be PRE-MEDICATED prior to dental treatment due to a heart condition or other medical condition?
Yes No
If yes, please provide the provider's name and contact information.
Does your child see a physician or other medical provider on a routine basis?
Yes No I would like assistance finding a physician and/or medical provider for my child. Yes
No
I would like assistance finding a physician and/or medical provider for my child.
If yes, please provide the provider's name and contact information.
Does your child currently take any medications (prescribed or over the counter)?
Yes No
Pleased list all medications below
The option "
Does your child have any of the following allergies? Please mark all that apply.
If yes, please describe allergies below.
The option "
Does your child have a history of any of the following? Please mark all that apply
Please describe any of the patient's prior medical history below that is not listed above
Please provide any additional detail that may be pertinent to patient's care
By providing my electronic signature, I am confirming the patient's medical record is accurate and current to the best of my knowledge.
* must provide value
Today M-D-Y
I have reviewed this patient information and answered its questions accurately, to the best of my knowledge. I understand that the answers I have provided will be used by the dentist to determine appropriate dental treatment for my child, and I agree to notify the dentist if any change in my child's health status should occur. I understand that Ascension St. Vincent must at times collaborate with other outside facilities to coordinate treatment and hereby authorize release of information to these facilities when necessary for treatment of my child. I authorize the dental staff to perform any necessary dental services my child may need. I acknowledge Ascension St. Vincent Pediatric Dental Clinic is a full service dental facility in which fees are charged per service(s) rendered on the date my child is treated. I authorize the dentist to release all information necessary to secure payment of benefits. I authorize my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I authorize use of this signature on all insurance submissions. I recognize Ascension St. Vincent coordinates dental appointments for my child with the school entity and staff and authorize my child to be seen on the dental bus during school or afterschool hours without my presence. I understand this dental information is required to be updated annually and this form will expire one year from the date I sign below, in which a new form must be completed in order for my child to receive dental treatment by Ascension St. Vincent Pediatric Dental Clinic.
* must provide value
By providing my electronic signature below, I am confirming receipt of the HIPAA Information Provided and understand its contents.
* must provide value
By providing my electronic signature below, I am confirming I give consent for the patient to be treated by the Ascension St. Vincent Pediatric Dental Clinic.
* must provide value
Consent for Silver Diamine Fluoride (SDF)
By selecting "yes", I am confirming that I give consent for the Ascension St. Vincent Pediatric Dental Clinic dentist to administer SDF treatment to my child.
Yes No
General supervision is the practice of dental hygiene services to a patient when the supervising dentist is not physically present in the location at which services are practiced. I understand that the dentist may not be physically present when my child has a routine cleaning.
* must provide value
Submit
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